A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?

Administer aspirin.

Measure blood pressure.

Administer nitroglycerin.

Initiate IV access.

Answer and Explanation

The Correct Answer is C

Choice A reason: Administering aspirin is one of the first interventions for a client experiencing acute angina because aspirin has antiplatelet properties that help prevent blood clots, which can reduce the risk of a heart attack.

Choice B reason: Measuring blood pressure is important but not the first action to take. It provides valuable information about the cardiovascular status of the client and can influence further treatment decisions.

Choice C reason: Administering nitroglycerin is a priority action for acute angina as it helps to dilate the coronary arteries and relieve chest pain. However, it is typically administered after aspirin unless contraindicated.

Choice D reason: Initiating IV access is an important step in the management of acute angina, as it allows for the administration of medications and fluids if needed. However, it is not the first action to take during an acute angina episode.

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Correct Answer is D

Explanation

Choice A reason: Petechiae on the chest are small, red or purple spots caused by bleeding into the skin and may be associated with various conditions, including infections. However, they are not a common finding in meningitis. Meningitis typically presents with symptoms related to inflammation of the meninges, the protective membranes covering the brain and spinal cord.

Choice B reason: Bradycardia, which is a slower than normal heart rate, is not a typical symptom of meningitis. While meningitis can affect various bodily functions, the classic symptoms are fever, headache, and neck stiffness, not changes in heart rate.

Choice C reason: Intermittent headache could be associated with meningitis, but the headaches that accompany meningitis are usually constant and severe due to the inflammation of the meninges. They are not typically described as intermittent.

Choice D reason: Photophobia, or light sensitivity, is a common finding in meningitis. The inflammation of the meninges can lead to an increased sensitivity to light, causing discomfort or pain when the patient is exposed to bright lights. This symptom, along with headache, neck stiffness, and fever, helps to distinguish meningitis from other conditions.

A. Decreased urinary output B. Emesis of 250 mL C. Decreased anxiety D. Increased respiratory rate to 26/min

Correct Answer is C

Explanation

Choice A reason: Decreased urinary output is not a direct indicator of morphine's effectiveness in acute heart failure. While morphine can lead to urinary retention, this is generally considered a side effect rather than an intended therapeutic outcome.

Choice B reason: Emesis, or vomiting, of 250 mL is not an indication of morphine's effectiveness. In fact, nausea and vomiting are common side effects of morphine and other opioids. If emesis occurs, it may necessitate further intervention.

Choice C reason: Decreased anxiety is a sign that the morphine is effective. Morphine has anxiolytic properties, meaning it can help alleviate anxiety, which is beneficial in acute heart failure where anxiety can exacerbate symptoms like shortness of breath.

Choice D reason: An increased respiratory rate to 26/min is not an indication of morphine's effectiveness and is a cause for concern. Morphine can depress the respiratory system, and an increased respiratory rate may indicate compensation for hypoxemia or the onset of adverse effects.

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A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has meningitis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is caring for a client who has acute heart failure and received morphine intravenously 30 minutes ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Correct Answer is C

Explanation

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